Gastroesophageal Reflux Disease (GERD) (cont.)

Jay W. Marks, MD

Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

How is GERD diagnosed and evaluated?

There are a variety of procedures, tests, and evaluation of symptoms (for example, heartburn) to diagnose and evaluate patients with GERD.

Symptoms and procedures to diagnose GERD

Symptoms and response to treatment (therapeutic trial)

The usual way that GERD is diagnosed - or at least suspected - is by its
characteristic symptom, heartburn. Heartburn is most frequently described as a
sub-sternal (under the middle of the chest) burning that occurs after meals and
often worsens when lying down. To confirm the diagnosis, physicians often treat
patients with medications to suppress the production of acid by the stomach. If
the heartburn then is diminished to a large extent, the diagnosis of GERD is
considered confirmed. This approach of making a diagnosis on the basis of a
response of the symptoms to treatment is commonly called a therapeutic trial.

There are problems with this approach, however, primarily because it does not
include diagnostic tests. For instance, patients who have conditions that can
mimic GERD, specifically duodenal or gastric (stomach) ulcers, also can actually
respond to such treatment. In this situation, if the physician assumes that the
problem is GERD, he or she will not look for the cause of the ulcer disease. For
example, a type of infection called
Helicobacter pylori, or
nonsteroidal
anti-inflammatory drugs (for example, ibuprofen), can also cause ulcers and these
conditions would be treated differently from GERD.

Moreover, as with any treatment, there is perhaps a 20% placebo effect, which
means that 20% of patients will respond to a placebo (inactive) pill or, indeed,
to any treatment. This means that 20% of patients who have causes of their
symptoms other than GERD (or ulcers) will have a decrease in their symptoms
after receiving the treatment for GERD. Thus, on the basis of their response to
treatment (the therapeutic trial), these patients then will continue to be
treated for GERD, even though they do not have GERD. What's more, the true
cause of their symptoms will not be pursued.

Endoscopy

Upper gastrointestinal endoscopy
(also known as esophago-gastro-duodenoscopy
or EGD) is a common way of diagnosing GERD. EGD is a procedure in which a tube
containing an optical system for visualization is swallowed. As the tube
progresses down the gastrointestinal tract, the lining of the esophagus,
stomach, and duodenum can be examined.

The esophagus of most patients with symptoms of reflux looks normal. Therefore, in most patients, endoscopy will not help in the diagnosis of GERD. However, sometimes the lining of the esophagus appears inflamed (esophagitis). Moreover, if erosions (superficial breaks in the esophageal lining) or ulcers (deeper breaks in the lining) are seen, a diagnosis of GERD can be made confidently. Endoscopy will also identify several of the complications of GERD, specifically, ulcers, strictures, and Barrett's esophagus. Biopsies also may be obtained.

Finally, other common problems that may be causing GERD like symptoms can be diagnosed (for example ulcers, inflammation, or cancers of the stomach or duodenum)
with EGD.

Biopsies

Biopsies of the esophagus that are obtained through the endoscope are not considered very useful for diagnosing GERD. They are useful, however, in diagnosing cancers or causes of esophageal inflammation other than acid reflux, particularly infections. Moreover, biopsies are the only means of diagnosing the cellular changes of Barrett's esophagus. More recently, it has been suggested that even in patients with GERD whose esophagi appear normal to the eye, biopsies will show widening of the spaces between the lining cells, possibly an indication of damage. It is too early to conclude, however, that seeing widening is specific enough to be confidently that GERD is present.

X-rays

Before the introduction of endoscopy, an X-ray of the esophagus (called an
esophagram) was the only means of diagnosing GERD. Patients swallowed barium
(contrast material), and X-rays of the barium-filled esophagus were then taken.
The problem with the esophagram was that it was an insensitive test for
diagnosing GERD. That is, it failed to find signs of GERD in many patients who
had GERD because the patients had little or no damage to the lining of the
esophagus. The X-rays were able to show only the infrequent complications of
GERD, for example, ulcers and strictures. X-rays have been abandoned as a means
of diagnosing GERD, although they still can be useful along with endoscopy
in the evaluation of complications.

Examination of the throat and larynx

When GERD affects the throat or larynx and causes symptoms of cough,
hoarseness, or sore throat, patients often visit an ear, nose, and throat (ENT)
specialist. The ENT specialist frequently finds signs of inflammation of the
throat or larynx. Although diseases of the throat or larynx usually are the
cause of the inflammation, sometimes GERD can be the cause. Accordingly, ENT
specialists often try acid-suppressing treatment to confirm the diagnosis of
GERD. This approach, however, has the same problems as discussed above, that
result from using the response to treatment to confirm GERD.